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DURHAM, N.C. -- A new study shows that individually
tailoring educational materials about hormone replacement
therapy (HRT) can help menopausal women better understand the
pros and cons of taking HRT and feel more confident about their
decision whether or not to undergo the therapy. These decision
aids could be posted on the Web or distributed in clinics to
assist women before clinical appointments to make better use of
limited visit time.

The study is published in the July 2002 issue of the
American Journal of Public
Health.

The rapidly changing knowledge about HRT, as well as the
increased number of women entering menopause, requires
innovative and flexible modes of communication about HRT, said
the researchers who conducted the study. The decision of
whether or not to use HRT can be a complex issue and may
require considerable education and counseling, which can take a
significant amount of time in an already short health care
visit.

The debate over the relationship between HRT and disease
revolves around the fact that the therapy might reduce the risk
of osteoporosis and improve quality of life. However, it also
carries a possible increased risk of breast cancer and may
cause heart problems in women with a history of heart
disease.

"HRT is a controversial topic, and there is no one answer
that's right for all women," said co-author Ilene Siegler,
Ph.D., professor of psychiatry at Duke University Medical
Center.

According to study co-author Colleen McBride, Ph.D.,
associate professor of community and family medicine at Duke
University Medical Center and director of the Cancer Prevention, Detection
and Control Program at Duke Comprehensive Cancer Center,
most information on HRT talks about general health risks and
benefits for women, but doesn't directly address an individual
woman's risk for breast cancer or her potential benefits from
HRT.

"We wanted to see if customizing educational materials about
HRT would personalize risk versus benefit in a way that would
help women feel confident about their decision," said
McBride.

In the study, 581 Durham County (North Carolina) women ages
45 to 54 were surveyed by phone. The women agreed to receive
written materials about HRT and did not have a history of
breast cancer. The baseline survey asked about the women's
perceived risk of breast cancer, overall health, knowledge of
HRT and their symptoms related to menopause. For each woman,
breast cancer risk factors were used to calculate a "Gail
score," a statistical scale that is used to calculate breast
cancer probability. This information was used to make each
woman a booklet explaining her health risks.

The women were divided randomly into two groups: one
receiving individually tailored educational materials about
their risk of breast cancer and information about HRT; the
other receiving the materials after the study was completed.
Follow-up telephone surveys were conducted at one and nine
months with both groups.

"The group of women who received the tailored materials were
more likely to be confident and satisfied with their decision
about HRT at both one and nine months than the control group,"
said McBride. "These materials made women more accurate in
their perceived risk of breast cancer. Many of these women were
over-concerned about their risk of breast cancer, and this
intervention helped them understand their true risk and weigh
that against the benefits of HRT."

Lori Bastian, M.D., a co-author and associate professor of
internal medicine and director of the Women's Health Program at
the Durham Veteran's Administration Medical Center, said that
while the women responded well to the booklet that helped them
in their decision-making, many women in the study did not share
the information or the process with their health care
providers.

"The best-case scenario would be that women use these
materials to help them make decisions and then talk them over
with their doctor, so women and their doctors move forward as a
team," said Bastian. "Shared decision-making by patient and
physician is the goal."

Another area that concerned the researchers is that older
women and African-American women seemed less likely to use the
materials.

"We're not sure if this was because the older women had
problems with using the materials or if African-American women
did not have as much interest in hormone therapies as white
women," said McBride. "It's difficult to know from this study,
but it's something we hope to examine in future studies."

Twenty-four percent of the women in the study were
African-American. McBride says that future studies should
include community involvement to recruit more African-American
women and women from a variety of socioeconomic
backgrounds.

But overall, the study is a promising first step, Bastian
said. "This study is just a model. As patients continue to take
a more active role in their health care, and as more complex
medical decisions arise from new technology -- such as genetic
testing -- we are going to need decision aids that can help the
both the patient and the health care provider move forward on
chosen path with confidence," she said.

The study was funded by the National Cancer Institute.
Additional co-authors are Susan Halabi, Ph.D.; Laura Fish;
Isaac M. Lipkus, Ph.D.; Hayden B. Bosworth, Ph.D.; and Barbara
K. Rimer.

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